The Role of Goal Setting in Self- Management of Diabetes Susan Michie Professor of Health Psychology...
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The Role of Goal Setting in Self- Management of Diabetes Susan Michie Professor of Health Psychology Director, Centre for Behaviour Change University College London, UK Diabetes in Primary Care Conference, Cork, Ireland, 2015 @SusanMichie
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Transcript of The Role of Goal Setting in Self- Management of Diabetes Susan Michie Professor of Health Psychology...
The Role of Goal Setting in Self-Management of Diabetes
Susan MichieProfessor of Health Psychology
Director, Centre for Behaviour Change
University College London, UK
Diabetes in Primary Care Conference, Cork, Ireland, 2015
@SusanMichie
Self-management
• Dictionary definition– the taking of responsibility for one's own behaviour and
well-being
• “Taking of responsibility”– Requires
• Capability, • Opportunity and • Motivation
Health Disease Disability and Death
Behaviour Behaviour
• To prevent ill health, manage illness, deliver effective health care
When is behaviour important?
Health professional behaviours affect health
• Many do not follow evidence-based guidelines for good practice e.g. – making referrals– giving advice– prescribing drugs– keeping hands clean
• Research– Netherlands: 30-40% of patients did not receive
‘evidence-based’ health care Grol et al, 2001– US: 20-25% received care that was unnecessary or
even harmful Schuster et al, 2005
• Every one of these requires multiple behaviours at
multiple levels – individual, organisational, state/national
• Each behaviour differs in context, barriers and drivers
Behaviours occur do not occur in a vacuum
Every behaviour is part of a system of behaviours ….• …that facilitate and compete with each other
– Within and between individuals
• Understanding the system of behaviours is necessary to identify where best to intervene and how
Understand the behaviour in context
• Why are behaviours as they are?• What needs to change for the desired behaviour/s
to occur?
• Answering this is helped by a model of behaviour– COM-B– Behaviour is part of a system and itself is a system
The COM-B system: Behaviour occurs as an interaction between three necessary conditions
Psychological or physical ability to enact the behaviour
Reflective and automatic mechanisms that activate or inhibit behaviour
Physical and social environment that enables the behaviour
Michie et al (2011) Implementation Science
Whose self-management?
• The person with diabetes• Those living with that person?• The practitioner offering support?• The manager providing infrastructure?• The commissioner deciding on the service?
Which behaviour to target in self-management
• Diet, physical activity, medication adherence, others?
• Questions to ask yourself– If I change this, what is the likely impact?
– How easy is it to bring about change?
– Spillover/generalisability to other behaviours and people?
– Preference, acceptability, cost?
Where does goal setting fit in?
Effective principles of behaviour change
• Maximise to regulate own behaviour– Develop relevant skills (e.g. goal setting, monitoring, feedback)– Develop specific plans to change
• Maximise to support self-regulation– Elicit social support– Avoid social and other cues for current behaviour– Change routines and environment
• Increase to engage in the desired behaviour– Reward change– Develop appropriate beliefs
• E.g. benefits of changing, others’ approval, personal relevance, confidence to change
– Develop positive feelings about changing• Reduce to continue with the undesired behaviour
NICE Guidance
for Behaviour change (2007)
NICE Guidance for Behaviour
change (2014)
If improve goal setting, what else changes?
• How does goal-setting fit in with other techniques to improve self-management?
Self-management is made up of many behaviour change techniques …
• “Active ingredients” within self-management support designed to change behaviour – Taxonomy of 93 behaviour change
techniques • Michie et al, Annals of Behavioral Medicine, 2013
• www.bct-taxonomy.com
93 item BCT Taxonomy v1,
Annals of Behavioral Medicine, 2013
BCT Taxonomy v1: 93 items in 16 groupings
Search for: BCTs
Search for: BCTs*
bcts.23.co.uk*
bcts.23.co.uk*
* You’ll need an internet connection to use the app
The BCTTv1 smartphone app
• Fully searchable version of BCTTv1
• Search by BCT label, BCT grouping or alphabetically
• Increases familiarity with the taxonomy
• Increases speed and recall of BCT labels and definitions
How does goal-setting ‘work’ to change behaviour?
• Self-regulation Theory explains how goal-setting works synergistically with other behaviour change techniques
• Goal Theory explains the kind of goal-setting most likely to be effective
Self-regulation (control) Theory: Carver & Scheier, 82
GOALCompare behaviour with standard
Discrepancy noted
Act to reduce discrepancy
Environmental influences
No discrepancy – goal reached
Disengage from goal – give up
SELF-MONITORING
GOAL-SETTING
ACTION-PLANNING
What techniques are effective in interventions to increase physical activity and healthy eating?
• Inclusion criteria– Interventions using behavioural &/or cognitive techniques – in adults– designs experimental or quasi-experimental – outcome measures objective or validated self-report
• 6 electronic databases, 1990-2007• Intervention content analysed using
– a reliable taxonomy of 26 BCTs (Michie & Abraham, 2009)
– a theoretically-derived combination of BCTs
• Random effects meta-analysis and meta-regression
Michie et al, Health Psychology, 2009
The interventions
• 84 interventions (n=28,838)
• Interventions ave. 6 techniques (range 1-14)– Many different combinations
• Effect d=0.37, 95% CI 0.29-0.54
• Very heterogeneous effects (I2=79%)– not explained by 10 moderators examined e.g.
• Setting, population, intervention characteristics, target behaviour
Results
• Only one technique, self-monitoring, had a significant effect for both behaviours across interventions– d=0.57, 14.6% variance
• Next step– Use theory to predict combinations of BCTs that might
be more effective– Self-regulation Theory suggests how feedback may
interact with other techniques to change behaviour Carver & Scheier, 1982
Theoretical combination of self-regulatory behaviour change techniques
• Self-monitoring PLUS• One or more of:
– setting goals– reviewing goals– feedback on performance– specifying action plans
Findings
• Interventions comprising self-monitoring with at least one other “self-regulatory” BCT (n=28)– compared with the other interventions (n=56)
• were twice as effective • d=0.60 vs d=0.26
– Michie et al, 2009, Health Psychology
• Replicated for overweight populations with co-morbidities – Dombrowski et al, 2012, Health Psychology Review
Self-regulation (control) Theory: Carver & Scheier, 82
GOALCompare behaviour with standard
Discrepancy noted
Act to reduce discrepancy
Environmental influences
No discrepancy – goal reached
Disengage from goal – give up
SELF-MONITORING
GOAL-SETTING
ACTION-PLANNING
• To what extent are these techniques delivered in practice?
• How well are they delivered?
Translating evidence into practice
Evidence/ theories of behaviour change
Techniques in manual
Delivery of techniques by professional
Participant response to intervention
e.g. physical activity
Self-management
Self-management
Intervention to increase physical activity of those at risk of Type 2 diabetes
• “ProActive”: 14 behaviour change techniques• Delivered by trained professionals in 5
sessions over 12 months• Specified in detailed protocols/manuals• An RCT of 365 people, family history &
sedentary– Increased activity by equivalent of 20 minutes
walking per day– No difference between intervention and “control”
groups
Kinmonth et al, Lancet, 2008
Behaviour ChangeTechniques
1. Give information2. Elicit questions3. Summarise message4. Set goals5. Self-monitor 6. Build motivation 7. Action plans
8. Use prompts 9. Use rewards 10. Build support 11. Review goals 12. Build habits13. Relapse prevention14. Generalise skills
Theories1. Theory of Planned Behaviour2. Relapse Prevention Theory3. Self-regulation Theory4. Operant Learning Theory
Question: What was delivered?
• 27 participants selected to study in depth
• Audio-recorded and transcribed sessions
• All discussion in sessions relevant to behaviour change was reliably coded into behaviour change techniques
Hardeman et al, Psychology & Health, 2007; Michie et al, Psychology & Health, 2007
% BCTs in protocol delivered by providers:
0
10
20
30
40
50
60
70%
45%
Quality of techniques
• Behaviour change techniques can be delivered more or less well
• Specific
• Measurable
• Achievable
• Relevant
• Timely
SMART Goal Setting
•A reliable measure of quality of goal-setting – developed in relation to
behavioural support for smoking cessation
Lorencatto et al (under review) Annals of Behavioral Medicine
0 Absence of goal setting
+1 Prompts goal setting (i.e. encourage client set quit date)
+1 Agrees clear quit date (dd/mm/yy)
+1 Agreed quit date within appropriate time frame (1-2 weeks)
+1 Quit date allows appropriate time to obtain medication
+1 Advice why cutting down doesn’t work so well
+1 Emphasise goal is to not smoke a single cigarette/puff
+1 Provide relevant normative information and examples
-1 Inappropriate goal setting (i.e. unclear date, incorrect time frame)
-1 Encourages or reinforces cutting down
-1 Undermines client commitment to quit date (i.e. imply flexibility)
Action Planning and If-Then rules…• Action planning
– Behaviour change is helped by a detailed action plan of how to change behaviour:
What are they going to do?
Where are they going to do it?
When are they going to do it?
With whom are they going to do it?
• ‘If-then’ rules– Specific type of action plan– Good evidence of effectiveness
Action planning: ‘If-then’ rules
• “If situation X arises then I will perform behaviour Y” • The situation becomes a trigger, or reminder, to perform the
behaviour
• For example, “If it is a weekday morning, then I will prepare a healthy lunch to take to work.”
Maintaining behaviour change
• Changing behaviour is hard– Maintaining that change is harder
• Effective strategies– Use the environment to support making behaviour
automatic• building routines• environmental support and prompts• feedback• rewards and incentives
Summary
• Effective self-management requires capability, opportunity and motivation
• Goal-setting is an important behaviour change technique– for everyone … patients, family, professionals
• Goal-setting works best within the context of other techniques
• Goal-setting can be delivered and used more or less well
Acknowledgements
• Health Psychology Research Group
• Key funders
For more information
• Susan Michie– [email protected]
• Books– www.behaviourchangewheel.com– www.behaviourchangetheories.com
• UCL Centre for Behaviour Change– www.ucl.ac.uk/behaviour-change
All proceeds from CBC teaching, training, books and products go to further development
